Primary Motility  Disorders of the  Esophagus
 The Esophageal
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 The
 Esophagogastric  Junction
 Barrett's
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OESO©2015
 
Volume: Barrett's Esophagus
Chapter: Dysplasia
 

Can a selective approach to the management of high-grade dysplasia be summarized? The role of the patient and the physician

S.J. Sontag (Hines)

The management of high-grade dysplasia (HGD) in Barrett's esophagus is controversial when adenocarcinoma is not present. Based on the often-quoted statement that 40% of patients with HGD already have adenocarcinoma, surgical esophageal resection continues to be recommended. Recent evidence, however, suggests that HGD existing without adenocarcinoma may follow a relatively benign course in many patients. The high morbidity and mortality of esophagectomy, along with the increasing incidence of esophageal adenocarcinoma, calls for a more complete understanding of the natural history of Barrett's esophagus and dysplasia.

Patients undergoing first-time screening endoscopy or patients undergoing long-term surveillance endoscopy may at some point in time be told they have HGD. What should the doctor do? What should the patient do? Regarding the patient's concerns, there are two types of fear: the prevalence fear and the incidence fear. The prevalence fear revolves around the numerous studies in the literature stating that 40% of HGD patients already have adenocarcinoma. The incidence fear revolves around two questions:
- what percentage of HGD patients will later develop adenocarcinoma?
- if adenocarcinoma does develop, will it be too late for surgery?

In the end, the therapeutic decision should be based on true informed consent, which itself should be based on the information available in the literature as well as the individual physician's experience.

The prevalence fear

The current recommendation for surgery in patients with only HGD is based on the results from several independent publications in which patients with a presumptive diagnosis of only HGD (without adenocarcinoma) underwent esophagectomy [1-9]. In these reports, unexpected co-existing cancer was found in the esophagectomy specimen in from 8% [1] to 73% [9], an average of 39%. Several factors may account for this high rate of "hidden" cancer:
1) erroneous definition of HGD (i.e., defining intramucosal adenocarcinoma as only HGD);
2) inclusion of patients with warning signs (i.e., nodules or Barrett's ulcers);
3) failure during the first year after diagnosis of HGD to aggressively endoscope, detect and exclude from the study those patients with an undetected prevalent adenocarcinoma.

From January 1979 to December 1998, patients were diagnosed through the Hines VA Hospital endoscopy screening and surveillance program. Endoscopies and biopsies were performed by two endoscopists using preestablished endoscopy terminology and biopsy criteria. The Hines VA protocol involved repeat endoscopic examinations at three-month intervals for the first year after a patient was initially diagnosed with Barrett's HGD. This portion of the protocol was extremely important in detecting patients with AdCa that was not detected on the initial endoscopic exam. For patients with low-grade dysplasia only, endoscopy was repeated at one or two years and then every two to three years if HGD or adenocarcinoma was not detected. For patients with no dysplasia, endoscopy was repeated at three to five year intervals.

One thousand ninety-nine patients have been diagnosed with Barrett's esophagus, and 36,251 esophageal mucosal specimens have been reviewed. Seventy-nine of the 1,099 patients (7.2%) initially had HGD (34 prevalent) or subsequently developed HGD (45 incident) without evidence of cancer.

Four of the 34 prevalent HGD patients (11.8%) were found during the first year of intensive searching to have unsuspected adenocarcinoma. All four had stage-one tumors: two were in a perfectly flat Barrett's mucosa and two were hiding in 2-3 mm bumps of an otherwise flat Barrett's mucosa.

The incidence fear

What percentage of HGD patients will later develop adenocarcinoma?

Of the 75 HGD patients without detectable cancer after the one year of intensive searching, 12 developed cancer (16%) during surveillance over a mean follow up period of 7.3 years:
- if adenocarcinoma does develop, will it be too late?
- nine had curative surgical resection, one had curative mucosal electrocautery ablation, one returned after a 10-year loss to follow up with a non-resectable cancer, and one refused any type of intervention. Cancer did not develop in the remaining 63 HGD patients during the surveillance period.

The decision-making role of the patient and physician. The role of the patient

From the data we have presented, it is clear (at least in our experience) that HGD without cancer in Barrett's esophagus followed a relatively benign course in the majority of patients. For the minority that eventually progressed to cancer during regular surveillance, surgical resection was curative, although not without morbidity. Thus, in the majority of patients with Barrett's HGD, surgical resection can be safely avoided providing that the mucosa is flat and that one year of intensive endoscopic searching does not reveal a coexisting cancer. Using this information, and the knowledge that surveillance endoscopies with biopsy is a valid and safe follow up strategy, the patient and the physician may be able to arrive at a somewhat rational decision. In the likelihood that an intensive one-year search is negative for adenocarcinoma, the patient can be reasonably certain that he/she has only a 15% chance of developing cancer in the subsequent seven years, and that if a cancer does develop, it is likely curable.

References

1. Cameron AJ, Ott BJ, Payne WS. The incidence of adenocarcinoma in columnar-lined (Barrett's) esophagus. N Engl J Med 1985;313:857-859.

2. Edwards MJ, Gable DR, Lentsch AB, Richardson JD. The rationale for esophagectomy as the optimal therapy for Barrett's esophagus with high-grade dysplasia. Department of Surgery, School of Medicine, University of Louisville, Kentucky 40292, USA. Ann Surg 1996;223:585-591.

3. Heitmiller RF, Redmond M, Hamilton SR. Barrett's esophagus with high-grade dysplasia. An indication for prophylactic esophagectomy. Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland 21287-5674, USA. Ann Surg 1996;224:66-71.

4. Levine DS, Haggitt RC, Blount PL, et al. An endoscopic biopsy protocol can differentiate high grade dysplasia from early adenocarcinoma in Barrett's esophagus. Gastroenterology 1993;105:40-50.

5. Streitz JM, Andrews CW, Ellis FH. Endoscopic surveillance of Barrett's esophagus. Does it help? J Thorac Cardiovas Surg 1993;105:383-388.

6. Rice TW, Falk GW, Achkar E, Petras RE. Surgical management of high grade dysplasia in Barrett's esophagus. Am J Gastroenterol 1993;88:1832-1836.

7. Pera M, Trastek VF, Carpenter HA, et al. Is Barrett's esophagus with high grade dysplasia an indication for esophagectomy? Ann Thorac Surg 1992;54:199-204.

8. Altorki NK, Sanagawa M, Little AG, Skinner DB. High grade dysplasia in the columnar lined esophagus. Am J Surg 1991;161:97-99.

9. Peters JH, Clark GWB, Ireland AP, et al. Outcome of adenocarcinoma arising in Barrett's esophagus in endoscopically surveyed and nonsurveyed patients. J Thorac Cardiovas Surg 1994;108:813-822.


Publication date: August 2003 OESO©2015